**1. Introduction**

For the last 100 years, healthcare has been dominated by the relentless application of a certain strategy in science known as reductionism. In this strategy the person is divided into ever smaller parts including organs, tissues, cells, organelles, proteins, and finally genetic material—RNA and DNA. This research strategy involves looking at how these parts influence each other and designing ways to control those parts. From this we have an explosion in knowledge of the parts of an individual and their mostly physical component interactions. This "knowledge of the parts" is then applied to a whole person by attempting to control these physical processes when they seem to be involved in disease. Treatment is framed almost entirely around controlling these component parts and attempting to balance the effectiveness of this control against the interference this control also places on normal, non-disease processes, producing unwanted effects.

Our theory is that in pursing the reductionistic strategy in science, we have neglected development of more "holistic" approaches of evaluation that provide more direct and relevant value for what matters in health care. Almost inevitably, the attempt to control one part of a complex system like a whole human being results in only partial effects

**Citation:** Jonas, W.B.; Rosenbaum, E. The Case for Whole-Person Integrative Care. *Medicina* **2021**, *57*, 677. https://doi.org/10.3390/ medicina57070677

Academic Editors: Robert H. Schneider, Mahadevan Seetharaman and Jimmy T. Efird

Received: 18 May 2021 Accepted: 28 June 2021 Published: 30 June 2021

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**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

(a small degree of efficacy) and adverse (unwanted) effects. Frequently, this produces more problems than it solves, and is fundamentally not designed to enhance the salutogenic and adaptogenic processes that rebalance a person's health as a whole [1,2]. In other words, the application of reductionism results in a focused attempt to control or remove the disease—to cure—rather than to restore the organism to optimal functioning—to heal.

Thus, there is a need to develop and use more "whole person" and "whole systems" strategies and evaluate their impact on health care outcomes, patient and provider experience and costs. This gap is now the focus of the strategic plan for the National Center for Complementary and Integrative Health (NCCIH), of the United States National Institutes of Health. [3] In his article we review some of these "whole person approaches" and evaluate their impact on the main outcomes desired in health care—clinical outcomes, experiences of care, and costs.

#### **2. A Whole Person**

A person is more than just their physical components or parts. They consist of the body and the external environment for sure but are also made up of at least three other dimensions including: (1) their behavior and lifestyle that interacts with the environment; (2) their social and emotional dimensions; and (3) their mental and spiritual dimensions, which bring meaning and purpose to life. These dimensions of what make up a human being have been defined by classic writers such as Abraham Maslow in the Hierarchy of Human Needs [4], Victor Frankel who demonstrated the importance of meaning for survival [5], and George Engel in his landmark work on the biopsychosocial model in biology and medicine [6].

How then can we develop health care that addresses the whole person in all his, her or their dimensions? Additionally, what evidence do we have that heath care models that incorporate whole person, rather than reductionistic models produce benefit on outcomes that matter, such as health outcomes, patient and provider experience and costs. In this narrative review, we describe several models of care that start from a holistic rather than a reductionistic perspective. We then review the selected literature for the impact these holistic approaches can have had on relevant outcomes. Our goal is to better, describe, define, and demonstrate the value of a new type of health care focused on the whole person.

#### **3. Examples of Whole-Person Models**

#### *3.1. Optimal Healing Environments*

Multiple models and operational frameworks have been created to conceptualize and deliver whole-person care. An example is the Optimal Healing Environment (OHE) framework developed by the Samueli Institute in 2003 [7]. Figure 1 illustrates this model. Several health care systems have used this framework for their operations and reported improved patient experience [8]. In addition, a comprehensive review of the business case benefits of this approach is published [9].

#### *3.2. Total Force Fitness*

Another example is the Total Force Fitness (TFF) model facilitated by the Samueli Institute and used by the US Military [10]. Figure 2 shows this model. TFF went beyond a medical environment to include physical, psychological, spiritual, social, and even economic aspects of human flourishing, integrated into a single framework and data collection system. This model sought to use a comprehensive whole-person framework for use in health care, as well as prevention and readiness within a military context. Multiple offshoots of this framework documented its value and are being applied in clinical settings such as the "Performance Triad" [11], in entire communities such as "Operation LiveWell", and the latest and most sophisticated version applied to the entire enterprise called the Holistic Health and Fitness (H2F) Program [12]. This program "recognizes that readiness depends on the proper combinations of physical fitness (such as strength, speed, and endurance) and foundational health (such as the cardiovascular, respiratory, immune,

and hormonal systems), which are optimized through careful attention to nutritional readiness, mental readiness, spiritual readiness, and sleep readiness". HF2 aims to track the total health and function of a person in real-time to optimize function, not just treat disease.

**Figure 2.** The Total Force Fitness Model.

#### *3.3. Whole Health*

Another, more recent model is currently being implemented in the Veteran's Health Administration (VHA) called Whole Health [13]. This approach starts with the mental and dimension, asking patients "what matters" to them in their life—their meaning purpose—and then capturing 10 areas of behavior, lifestyle, and social support to create "personal health plan" based on those assessments. Recent research on the outcomes this model has found significant improvements in all major areas and will be reported later in this review. 3 illustrates this model.

spiritualandafromonFigure

**Figure 3.** The VHA Whole Health Model.

#### *3.4. Integrative Health*

The latest evolution of what has been called complementary and alternative medicine is integrative health. Integrative health involves the optimal combination of all evidencebased approaches to help heal the person as a whole. Integrative care defines itself as the appropriate merger and integration of conventional care, drugless approaches, including complementary and alternative medicine (CAM), and behavior and lifestyle medicine. Integrative medicine and integrative health are being used by over 70 academic health centers in the U.S. and Canada, which have formed an organization called the Academic Consortium for Integrative Medicine and Health. The University of California, Irvine is the first major University to completely embrace this approach with others following [14,15]. Figure 4 illustrates this approach.

#### *3.5. Advanced Primacy Care*

Integrative health care is part of a larger type of whole-person primary care we have recently described as Advanced Primary Care [16]. Briefly this model begins with the basic transaction with the patient, the encounter, and the therapy, but then surrounds that transaction with three additional circles of care that enhance or enable whole-person care. In the first circle are the components of the Starfield model of primary care that includes first contact, comprehensive and continuous care. Then, a second circle using enhanced managemen<sup>t</sup> systems for care is provided to better integrate care delivery. This circle includes chronic disease management, enhanced care coordination, pharmacy services, and the integration of mental health. The fourth and final circle brings in support for lifestyle change and CAM and a process for addressing the social and economic determinants of health. Integrative health has a role in supporting behavioral and lifestyle determinants. Figure 5 illustrates this model.

**Figure 4.** The Integrative Health Model.

**Figure 5.** The Advanced Primary Care Model.

These models are only illustrative and not exhaustive of whole-person examples. To explore the impact that whole-person care models have on outcomes, we analyzed four aims of health care considered essential for quality. We used the outcomes described by the Institute for Healthcare Improvement called the Triple Aim [17,18] and added one additional aim (provider experience) to the analysis. The Triple Aim includes: (1) health improvement; (2) experiential outcomes in the form of patient satisfaction; and (3) cost reduction outcomes in the form of lowered costs per capita.

#### **4. Materials and Methods**

We selected studies focused on the models of whole-person care and included a few that emerged from the search based on broader health system data. We included relevant examples of programs with elements of coordinated delivery in at least three elements: conventional medical care, complementary and alternative medicine, and self-care within the social context of the patient. We looked for outcomes based on the Triple Aim criteria, plus the provider experience.

Two iterative Pubmed and Google searches were conducted between December 2020– May 2021 (last search done 15 May 2021) to seek studies looking at outcomes of wholeperson outpatient primary care models. Search criteria used the search terms "Whole Health Veterans Administration", "integrative medicine", "integrative health", "complementary and alternative medicine", and, as they related to the outcomes, "health outcomes", "costeffectiveness", "cost reduction", "patient satisfaction", "provider satisfaction", and "physician satisfaction". Inclusion criteria were models being in primary care, not done in a single sub-population or specially, not using a single modality or outcome measure, and only United States practices. After reviewing the citations from studies in the initial search, we conducted a second search, using the same criteria in Google.

To explore the business impact more clearly, we then conducted a deeper dive into the Veteran's Health System and Southcentral Foundation as existing models of wholeperson care which have had extensive evaluation. We review and describe these findings in more detail.
